Everyone Secretly Hates Fat People?

This blog was inspired by my paper discussing the content and accuracy/quality of that content on weight loss and weight acceptance blogs, so I figured I should look at one of the issues commonly addressed (indirectly, usually, but sometimes directly) in the fatosphere.

The fatosphere, first off, is like a pocket of the blogosphere dedicated to fat acceptance. It's pretty fun and I learned a lot about perspectives and experiences very different from mind. From an anthropological view, I had a great time writing that paper.

This week's post is dedicated to thin privilege, and I will be looking at it through the lens of physician bias. 

Now, I'm not here to degrade the work of any doctor. I applaud anyone who works in the healthcare system to improve the lives of other human beings and, in many cases, to save some of those lives. So far, this blog has been just me but I have dreams of a grander future and I do not want to give the impression that doctors of any kind are bigots by nature. 

But...

Several studies^{(1, 2, 3, 4)} have found a significant weight bias among physicians, even those who research or work with obese patients. Some results have suggested this negative bias extends to other institutionalized forms of discrimination, including adoption proceedings⁽⁴⁾. There is compelling research to show we can use social pressure to change such biases among physicians⁽⁵⁾, but the unsettling truth is that it is there in the first place. 

Similarly, while there is evidence to suggest that moderate weight loss can alleviate chronic illnesses like hypertension (a precursor to heart disease) and hyperlipidemia⁽⁶⁾ and diabetes^{(7, 8)}, one study showed some doctors will treat the chronic illness instead of the obesity⁽²⁾.

Schwartz and colleagues used the Implicit-Associations Test to examine the subconscious biases of clinicians and researchers attending an international obesity conference and found a statistically significant amount (p<.0001) maintained an anti-fat bias⁽⁹⁾. These are people who understand obesity better than any other doctor, they know it has multiple causes, and a significant number still have an anti-fat bias. 

Is it clear why I put the disclaimer about doctors at the top? It's important to remember that the IAT is an *implicit* associations test. No one started it thinking fat people were lazy and worthless, at least not consciously. The point of this is that this stigma extends so deeply in many Western societies that even the obesity experts may still have a bias. This may interact with the fact that their job is often figuring out how to reduce obesity, but it does not justify or explain any bias.

Where does biology or biomedicine come in to this? Well, it doesn't. By itself. But in the healthcare system where such strong bias exists, where health professionals (doctors, nurses, researchers, etc.) who are entrusted with the care of the sick may implicitly avoid the necessary treatment out of a subconscious bias, these problems will be nearly unsolvable. When less than 50% of physicians feel confident in their ability to prescribe weight loss programs and only 14% believe they are successful in treating obesity(2), how can we expect to fight the "obesity epidemic" and help those who are unhealthy and obese? 

We can't. And this is why healthcare needs more anthropology. 

More on that next week.

Cheers,

J.G.

1) Schwartz, M. B., Chambliss, H. O. N., Brownell, K. D., Blair, S. N., & Billington, C. (2003). Weight bias among health professionals specializing in obesity. Obesity research, 11(9), 1033-1039.

2) Foster, G. D., Wadden, T. A., Makris, A. P., Davidson, D., Sanderson, R. S., Allison, D. B., & Kessler, A. (2003). Primary care physicians’ attitudes about obesity and its treatment. Obesity Research, 11(10), 1168-1177.

3) Jay, M., Kalet, A., Ark, T., McMacken, M., Messito, M. J., Richter, R., & Gillespie, C. (2009). Physicians' attitudes about obesity and their associations with competency and specialty: A cross-sectional study. BMC Health Services Research, 9(1), 106.

4) Puhl, R., & Brownell, K. D. (2001). Bias, discrimination, and obesity. Obesity research, 9(12), 788-805.

5) Puhl, R. M., Schwartz, M. B., & Brownell, K. D. (2005). Impact of perceived consensus on stereotypes about obese people: a new approach for reducing bias. Health Psychology, 24(5), 517.

6) Goldstein, D. J. (1992). Beneficial health effects of modest weight loss.International journal of obesity and related metabolic disorders: journal of the International Association for the Study of Obesity, 16(6), 397-415.

7) Lifshitz, F., & Hall, J. G. (2002). Reduction in the incidence of type II diabetes with lifestyle intervention or metformin. J Med, 346, 393-403.

8) Knowler, W. C., Fowler, S. E., Hamman, R. F., Christophi, C. A., Hoffman, H. J., Brenneman, A. T., ... & Steinke, S. C. (2009). 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet, 374(9702), 1677-1686.

9) Schwartz, M. B., Chambliss, H. O. N., Brownell, K. D., Blair, S. N., & Billington, C. (2003). Weight bias among health professionals specializing in obesity. Obesity research, 11(9), 1033-1039.

Space, the Final Frontier (for Airplane Seat Designers)?

I know this blog has gotten off to a rocky start, but now that I'm mentally weaning myself off winter break, I'm no longer sick, and I have a computer that works, we should be much better moving forward.

Is "airplane seat designer" a real job by itself? It is for this post.

Last time, I wondered about the effects of obesity and tiny airline seats. The typical airplane seat is 17-inches wide, which I have found is barely big enough for me and I'm of average size. And I'm a woman. The average man has broader shoulders than I do so we will always be rubbing arms and hating each other no matter what.

I wondered specifically about long-haul flights (four hours or more according to the article I will be using, but also used to reference trans-oceanic or overnight flights) in mind and how temporary sedentism can exacerbate the effects of chronic sedentism when the person is squeezed into the airplane seat. I recently had to sit through a couple of these, and my own joints get stiff and sore despite being young and healthy.

Unfortunately, no one has wondered quite the same thing I have and I could not find any research regarding staying seated in cramped spaces for four hours or more. I did find one article that touched on this so I will be speculating off of this.

It should be noted that I am focusing specifically on the size of the seats. Research has been done on leg room and passenger comfort and I acknowledge that the loss of leg room over the years in aircraft carriers hoping to maximize seating contributes to the general problem. I would like to say that this may worsen conditions that result from having one's legs bent for long periods of time, especially cardiovascular problems.

So, as airplanes have been getting larger and making longer flights, airlines have been working to maximize seating while providing guest comfort, especially on long haul flights⁽¹⁾. Dampening the noise from the engines, changing engine location, creating ergonomically designed seats, and adjusting for crossing time zones and changes in cabin pressure have all been strategies used to promote passenger comfort (and thus health). It should be noted that the airlines recognize the threat of edema, thromboses, and cramps but arrangements to actually relieve these problems (more leg room or incentives to get up and move around for a few minutes every couple of hours, if not more frequently) have been slow to be incorporated.

The point of this is the conflicting pressures. Airlines want to make the most money as possible, which means making passengers comfortable while maximizing seating. Larger passengers, especially overweight or obese passengers, are pressured to keep to their own space and take responsibility for the burden they impose on others when they do not fit into their own seat. Airlines are pressured to create policies to meet the needs of obese and non-obese customers but often fall very short of this or outright fail in the process. In addition, the negative health effects of sitting for four or more hours may not be immediately realized on the plane, but considering many Americans lead fairly sedentary lives, such seating certainly makes things worse.

Here, the interaction of health (affording adequate seating for all passengers to minimize risk of health detriment) and society (pressures on airlines, passengers of size, and average passengers) offer no win-win solution. Ideally, there may be a middle ground in which airplanes are designed with enough comfort and space to reduce health risk and passenger overlap while maximizing profit for the airline itself. However, even if such a middle ground existed, the ever-changing fluctuation in population body size averages and extremes would quickly make it irrelevant.

I don't have an answer, here, and the point of this blog isn't to find answers but rather to ask more questions that take into account multiple factors and how social and biological needs intersect. So, I would ask here, is it possible for everyone to be happy given the current cultural paradigm toward passengers of size? Or do we need to change the way we think about each other, especially during an activity as stressful as air travel? How responsible is a larger person for the space they occupy when they aren't fat through any particular action or will of their own? Finally, what other parallels are there in travel or anytime many people of different shapes and sizes get to together for hours on end that could benefit from finding an answer to the air travel problems?

Next post on Thursday with a new topic!

Cheers,
J. G.

1) DeHart, Roy. 2003. Health Issues of Air Travel. Annu. Rev. Public Health. 24:133-151

Computer Death

Computer issues, no post this week. Also, new posts will now be made on Thursdays to fit better with my work schedule.

Cheers,
J. G.

Obesity and Airlines Part 2: Rise of the 18-inch Seat

Happy holidays!

I can see again! 

It occurs to me I tend to post very long things so I'm going to start breaking topics up into shorter posts, next week.

This week, it's about Airbus.

Airbus, an airplane manufacturer that sells its productive primarily to non-U.S. companies, has introduced wider seats on its planes in the hopes of increasing revenue and comfort. Instead of the standard 17-inch-wide seats, Airbus is pushing to make 18-inch-wide seats the new standard⁽¹⁾ as well as introduce a 20-inch-wide seat for passengers who require more room⁽²⁾. The 20-inch-wide seat was introduced on one specific model, the A320 passenger aircraft. Long-haul, international flights appear to be the current target for this new standard, but Airbus hopes to break into the U.S. market with these more comfortable seats and out compete Boeing (it's main competitor) through word of mouth and social media marketing⁽³⁾. 

Obviously, the larger the seat the higher the cost, but with airplanes feeling smaller and more cramped, Airbus is convinced people are willing to pay a little extra for more comfort.

The really interesting thing here is that Airbus is marketing it's 20-inch-wide seat (of which there are only two, each an aisle seat, forcing the remaining two seats in the row to be 17-inch-wide seats) as available to anyone who would like to pay for it. They market it as a seat for extra comfort, acknowledging that their passengers are bigger and taller, but also that it might be useful for parents with small children on their laps. 

They released a video to the international aircraft community describing the 17-17-20 arrangement:  http://www.aircraftinteriorsinternational.com/wide_seat_video.php

So, it's not quite what I had in mind but it's a start. 

What I would like to see, because Airbus is using a sleep study from the London Sleep Centre⁽¹⁾ to tout the health benefits of their 18-inch-wide seats, is whether or not these seats benefit the health of larger passengers or if that benefit is limited to those who didn't "need" the extra space. None of the articles I found discussed leg room, either, so how do these new seats address that problem? Also, is 18 inches really enough for American passengers who would otherwise have to purchase an extra seat? Is 20 inches? 

This brings me to the end of this post but I think I'll look into the health effects of flying across the country or internationally frequently or at all. Considering this is a largely sedentary, cramped, stressful situation endured by largely sedentary, stressed individuals, I would imagine short term effects would exist, especially if the stress response is allowed to persist for the entire flight. Add in the effects of obesity and, well, I guess I'll have to get back to that next week. 

Cheers,
J. G.

1) Petroff, Alanna. October 28, 2013. Airbus calls for wider seats on long flights. Accessed 12/15/13. Retrieved from: http://money.cnn.com/2013/10/28/news/companies/airbus-wider-seats/

2) Francis, Enjoli. May 25, 2012. Airbus to offer extra wide seats on new planes. Accessed 12/30/13. Retrieved from:

http://abcnews.go.com/blogs/lifestyle/2012/05/airbus-to-offer-extra      wide-seats-on-new-planes/

3) Saporito, Bill. November 2, 2013. Airbus is Trying to Convince Airlines to Make More Room for Your … Behind. Accessed 12/30/13/ Retrieved from:  http://business.time.com/2013/11/02/airbus-is-trying-to-convince-airlines-to-make-more-room-for-your-behind/

It's the Holidays...

... and I've wrecked my eyesight with staring at a computer screen writing papers and whatnot for science (and grades). So, this Monday's post will have to be delayed a couple days.

That said, I have found some interesting information regarding new airplanes designed just the way I mentioned they should be last week, so I look forward to the part 2 of this post.

When I can read words on a computer screen without them being all blurry and headache-inducing, I'll be back. Probably a couple days.

Happy holidays!

Cheers,
J. G.

Obesity and Airlines Part 1

The end of the semester is a busy time for anyone in academia and I'm certainly no different. As a result, this post will be a little social-heavy, but last week's metabolic obesity plays another important role here. 

I am of fairly average size. I am not tall, not short. I am neither thin nor fat (I'm actually a bit of an athlete, so my BMI puts me at "overweight" but I'm in pretty decent shape). 

One nice thing about being size-average is flying is not much of a problem for you. I don't have to worry about weight-limits for any thing like skydiving, hang gliding, etc. etc. On an airplane, I don't have to worry about armrests cutting into my sides or the person next to me being bothered by my just sitting down. Neither am I expected to put up with invasions of space because I am so thin that there is plenty of space to spare. I also usually have enough leg room. 

If it's not clear, this post is about obesity and airplanes. 

Flying from place to place is a privilege, not a right, but airlines are trying to maximize profit and marginalizing, discriminating against, or simply not-serving two-thirds of the American population is no way to do that. I don't think anyone books a flight thinking if they have to spend 6 hours next to someone who needs more than one seat that they'll just stay home, but they might fly on a different airline next time. 

Basically, there are three major perspectives here:

1) The "passenger of size" who requires more than one seat 

2) The passenger who does not require space beyond their own seat to exist

3) The airline company

I'm in the second category and I cannot speak for either the first or third categories, but I can consider them in this ongoing debate.

Canada Air allows passengers of size to procure an extra seat for free if they have a note from their doctor and fill out a form, equating obesity to a disability⁽¹⁾. This is due to a legal ruling indicating charging passengers for an extra seat because of obesity is illegal discrimination⁽²⁾.

The American Federal Airlines Administration requires passengers to be able to lower both armrests and buckle their seat belt before requiring them to buy an extra seat (2), but different domestic airlines have different ways of adding to this.

Most airlines require passengers of size to foot the bill for a second although some will offer a full or partial refund for the second seat after the plane has landed. However, Delta does not require (it advises) passengers of size to purchase an extra seat even if they don't fit in one seat (however, they may be asked to move, or take a later flight with more room). Spirit Airlines has "Big Front Seats" with more space available and passengers of size are advised to choose those. 

An article this year in the Washington Times revealed 63% of Americans believe overweight/obese passengers should be required to purchase an additional seat if they can't fit in one⁽³⁾. Even if that includes the entirety of the 25% or so of Americans who aren't overweight or obese, that's still 38% of the overweight/obese who are on board with buying a second seat if you can't fit in one. 

There are two major things I'm pulling from reading about these policies:

1) There is a societal attitude that a person is responsible for the space they take, and that responsibility includes being considerate of the space of others

2) How will making obesity a disease/disability change airline policies?

I would like to mention that such policies and attitudes may effect people who would be considered passengers of size but are not overweight/obese. Since this blog is about the interaction of obesity and health, those passengers will not be considered.

So we have the overall dilemma of how to meet the space needs of passengers without punishing passengers of size. 

I think it is truly impossible to be neutral or find a perfect solution to this dilemma. Obviously, a great solution would be for airplanes to have larger seats or a greater percentage of seats that can accommodate larger passengers properly (perhaps every other row would be two wider seats instead of three current-sized seats). However, this is unrealistic as it would call for redesign of the planes and a change across all airlines with a likely loss of profit, so I think we can all accept that's not going to happen.

It would seem then that the requirement that passengers of size reserve two seats is the most realistic solution. However, while this is easy enough to put onto paper, it's a pretty short step from this to justifying it with stigma and discrimination. The question now is could such a policy even be implemented without sounding like a discriminatory policy? 

I like Canada Air's policy of offering a free second seat for those disabled by obesity (presumably described as taking up too much room on an airplane, along with any other health consequences such as difficulty breathing). I don't like how easily that policy could be abused by people who don't need it or don't need it and are jealous of those who do and get extra room. I do think people who don't fit in one seat need to have a second, adjacent seat reserved, whether or not they have to pay for it, given current plane design and policies. 

The final question that this leads up to is: 

Finally, is it discrimination to require passengers of size to purchase an extra seat on a plane (with or without a refund) and, if it is not discrimination, does that mean it won't be socially stigmatized?

Things to consider:
Any treatment that could be considered preferential or different is going to be met with social pushback.

Not everyone who requires extra room is disabled and may now qualify for disability rights

How does personal liberty to be obese interact with personal responsibility and space?

Sorry if this post was a little disjointed, did I mention it's the end of the semester? I'm actually working on a paper looking at blogs as resources for information and support for obesity-related matters. While I will eventually be posting that essay, I think that I will use some of those sources and make this airline post a two-parter so I can look into how others have responded to this question next week. Maybe I'll have a real informed opinion next week instead.

See you next Monday!

Cheers,

J. G.

1: Air Canada. Customers with Special Needs: Special Seating. Accessed 12/15/13. Retrieved from: 
http://www.aircanada.com/en/travelinfo/before/specialneeds/specialseating.html

2: CheapAir. April 29, 2013. Airline Policies for Overweight Passengers Traveling this Summer. Accessed 12/15/13. Retrieved from:  http://www.cheapair.com/blog/travel-tips/airline-policies-for-overweight-passengers-traveling-this-summer/

3) Harpur, Jennifer. April 23, 2013. Fat chance? 63 percent of Americans say obese airline passengers should be required buy a second seat. Accessed 12/15/13. Retrieved from: http://www.washingtontimes.com/blog/watercooler/2013/apr/23/fat-chance-63-percent-americans-say-obese-airline-/

Metabolically Healthy Obesity

Metabolically healthy obesity is a very complicated concept, but I'll just cover the basics here because it's the end of the semester and I haven't been able to read as much into the hormonal and cellular changes as I would like to include them. Also, I prefer to not make essays out of blog posts.

While reading various reviews and studies for this post, I noticed that no one really knows how to define "metabolically healthy obesity" and a lot of people like to talk about that. I went over a few large-scale literature reviews that lamented the lack of a definition but also failed to provide one, despite having amassed all of the literature over a decade or two on the subject. 

So, unfortunately, I will be going with the bare-bones idea of metabolically healthy obesity:  

Simply put, a metabolically healthy but obese (MHO) person is someone who would be classified as obese based on body fat percentage but is "resistant to the metabolic disturbances associated with obesity"⁽¹⁾. The metabolic disturbances primarily include low insulin sensitivity, high LDL cholesterol, low HDL cholesterol, and high plasma triglycerides. Some authors include inflammation and cardiovascular risk but there is quite a bit of disagreement on whether or not MHO individuals are protected against CVD.

Karelis et al. (2004) Primeau et al. (2011) and Stefan et al. (2013)^{(1, 2, 3)} conducted large-scale literature reviews to determine criteria or common characteristics of MHO individuals compared normal weight or metabolically abnormal obese (MAO) individiuals. Although neither proposed specific guidelines, it  was clear that MHO have identifiable differences from their metabolically abnormal counterparts.

MHO individuals were much more likely to have less visceral and ectopic (out of place) fat in the liver and skeletal muscle, and an overall healthier metabolic profile. In addition, there were interesting differences between effects of exercise and restrictive diets, such that MAO individuals were more likely to see a reduction in metabolic and cardiovascular risk factors but MHO tended to maintain their profiles. 

Although both reviews mentioned the effects of diet and exercise, both also mentioned the need for more studies on the differences between MHO and MAO individuals regarding energy intake and use. In addition, I think we need more information regarding the effects of body mass itself on joint and respiratory health in MHO.

If that is the research/biomedical side of things, what does the social/anthropological side have to say?

Honestly, when I look at the headlines for Google searches like "healthy obesity," "metabolically healthy obesity," and "fat but fit" and read some of the articles, I really think I'm looking at people who know they have something really cool on their hands but don't know what to do with it. They don't know the science well enough to understand the difference between being completely healthy and metabolically healthy or they don't want to come down on the wrong side of what is clearly a new thing in science. 

Any kind of "good" obesity is going to be a bit much for the average person to wrap their head around. Even people I've spoken to who understand human anatomy and cell biology and whatnot tend to have trouble with it. Heck, I had trouble with it when the matter was first brought to my attention, and even now I read the research looking for clues that something isn't quite right just because I have spent all my life being told obesity is basically an early death. 

Can we take a minute to recognize how interesting that is? The average American's (or Westerner's) view of obesity is largely a product of a culture which both promotes consumption of excess and sanctions some of those who participate. Never mind the idea that being metabolically obese could be a huge evolutionary advantage (although, the evolutionary aspect of this might not be relevant until the mechanism is better understood, which is sad because I really wanted to talk about that). 

I think what this comes down to is a simple acceptance of human variation. If we accept that human variation exists across all phenotypes, then we can research, write and talk about obesity with reduced bias in scholarly articles and the public sphere. It wouldn’t be so difficult to understand that obesity does not equate with complete health deterioration, nor does it indicate personality traits. Sometimes that variation is "bad" from an evolutionary standpoint because it decreases the chances of reproduction and sometimes it is "good" for the opposite reason. 

In sum, I have glossed over metabolically healthy obesity because it is very complicated and fun to read about. People don't know how to talk about it because of our culture. Human variation is a fantastic thing. 

See you next Monday!

Cheers,
JG

1: Karelis, A. D., St-Pierre, D. H., Conus, F., Rabasa-Lhoret, R., & Poehlman, E. T. (2004). Metabolic and body composition factors in subgroups of obesity: what do we know?. Journal of clinical endocrinology & metabolism, 89(6), 2569-2575.

2: Primeau, V., Coderre, L., Karelis, A. D., Brochu, M., Lavoie, M. E., Messier, V., ... & Rabasa-Lhoret, R. (2010). Characterizing the profile of obese patients who are metabolically healthy. International Journal of Obesity, 35(7), 971-981.

3: Stefan, N., Häring, H. U., Hu, F. B., & Schulze, M. B. (2013). Metabolically healthy obesity: epidemiology, mechanisms, and clinical implications. The Lancet Diabetes & Endocrinology, 1(2), 152-162.

 NOTE: The literature reviews I have cited include data from multiple decades and, to avoid making this post 90% citations, I have decided to cite the reviews themselves, which summarize the information. Credit for the work goes to the original authors (and if I were publishing in a journal, every single one would be properly cited). Please refer to these articles for further reading.